Approach to Swollen Legs

Louis F. Knoepp, M.D., FACSAnMed Vascular Medicine

February 25, 2017

Disclosures……

…..I am NOT Dr. Thomas

Disclosures

Objectives

• Review major causes of leg edema

• Focus on vascular causes, mainly venous insufficiency and lymphedema

• Review current therapies for treatment of both conditions

How many times do you see this a week?

Major Causes of Leg Edema

• Heart Failure• Renal disease• Medication related (NSAIDs, steroids, etc)• Nephrotic syndrome/liver disease• Malnutrition• Venous obstruction or insufficiency• Lymphedema

Venous disease

• May cause unilateral or bilateral edema• If edema is acute and unilateral, of course

always need to rule out DVT• Very common to see post-thrombotic

syndrome after episode of thrombophlebitis• Chronic venous insufficiency is also

extremely common

Prevalence of Venous Insufficiency

Risk Factors for Venous Disease

• Advancing age• Family history of venous disease• Prolonged standing• Obesity• Sedentary lifestyle• Lower extremity trauma• History of DVT/SVT• Pregnancy

Pathophysiology

• Inadequate calf muscle pump function• Incompetent venous valves (reflux)• Venous thrombosis/obstruction

• ALL LEAD TO VENOUS HYPERTENSION, which initiates changes leading to vein dilation, skin changes, and ulceration

Progression of disease

• Increasing severity of symptoms appears to be related to extent of valvularincompetence

• Reflux is diagnosed by duplex ultrasound showing retrograde or reversed flow of >0.5 second duration*

Clinical Features

• Symptoms: pain, leg heaviness/aching, swelling, dry skin, tightness, itching

• Signs: dilated veins, edema, hyperpigmentation, lipodermatosclerosis (a fibrosing dermatitis of the subcutaneous tissue), ulceration

CEAP categories

Initial Conservative Management

• Treatment goals: improvement of symptoms and appearance, reduction of edema, healing of ulcers

• Always start with leg elevation, exercise, and compression therapy

• Stasis dermatitis responds to topical agents• Venous ulcers should be treated with wound

care and compression bandaging

Vein Ablation therapy

• Most insurance carriers require a minimum of 3 months of conservative therapy prior to ablation*

• If symptoms persist, and the patient has documented reflux on duplex, then ablation is the next step

Radiofrequency Ablation (RFA)

RFA

Recent VNUS patient

Non-thermal ablation

• Newer technologies being introduced, eliminate the need for tumescent anesthesia (ie, less needle sticks)

• VenaSeal (Medtronic)• Cyanoacrylate “super glue” used to close

incompetent saphenous veins• No compression needed afterwards,

immediate return to normal activities• No CPT code yet, expected later this year

Non-thermal ablation CONT

• Clarivein (Vascular Insights)• Uses sclerotherapy technique with 360-

degree catheter to close saphenous without heat

• Faster return to normal activities• Just gained CPT code end of 2016,

reimbursement being negotiated

Lymphedema

• Accumulation of fluid and fibroadiposetissue due to disruption of lymphatic flow

• Can be primary but more commonly secondary (malignancy, recurrent cellulitis, obesity, lymphatic damage from surgery, burns, or radiation)

Lymphedema

• Conservative treatments are best, with limb elevation, maintaining a healthy body weight, exercise, meticulous skin hygeine, low threshold to treat cellulitis with antibiotics, avoiding limb constriction

• Also implement compression garments, possibly intermittent pneumatic compression, and manual lymphatic drainage massages (** Jean Nourse **)

Summary• Patients with symptoms of venous

insufficiency, especially those found to have venous reflux, should be referred to a vein specialist for further evaluation and management

• Remember to document the initiation of conservative management with compression hose

• For those with lymphedema, we have excellent resources in occupational therapy

Approach to Swollen LegsDisclosures………..I am NOT Dr. ThomasDisclosuresObjectivesHow many times do you see this a week?Major Causes of Leg EdemaVenous diseasePrevalence of Venous InsufficiencyRisk Factors for Venous DiseasePathophysiologyProgression of diseaseClinical FeaturesCEAP categoriesInitial Conservative ManagementVein Ablation therapyRadiofrequency Ablation (RFA)RFASlide Number 19Recent VNUS patientNon-thermal ablationNon-thermal ablation CONTLymphedemaLymphedemaSummary